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DROWNING A form of asphyxia leading to death due to aspiration of water into the lungs


TYPES OF DROWNING Wet Drowning / Primary Drowning Water enters the lungs Dry Drowning 10% of all cases. Intense laryngeal spasm prevents entry of water into the lungs


AETIOLOGY (By age) Infants and Young Children Domestic bath, Garden pools Adolescents Swimming pools, rivers or other bathing sites Adults Water sports, Boating, Fishing, Occupational Older people Domestic Baths


PATHOLOGY LUNGS It differs in fresh water drowning and sea water drowning. In either case, following inhalation of water, rapid onset of V-P mismatch leads to hypoxemia and diffuse pulmonary oedema

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IN FRESH WATER Water gets rapidly absorbed in the lungs leading to hemodilution and hemolysis. Potassium ions are released from RBC. Water washes away the surfactant leading to alveolar collapse. IN SEA WATER Hyperosmotic fluid promotes alveolar oedema and respiratory failure by shifting fluid into the alveoli. Hypernatremia occurs later

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HEART Arrhythmias like VF, Cardiac arrest. ECG may show non specific changes. KIDNEYS ATN – in case of fresh water drowning due to hemolysis and prolonged hypotension. CNS Asphyxia leads to LOC, Cerebral oedema, Convulsions Anoxic encephalopathy – transient hemiparesis, quadriparesis, choreoathetosis, aphasia and facio brachial weakness.

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In addition, Impurities and contaminants – bacterial infection – Atelectasis Pneumonia Lung abscess


CLINICAL FEATURES Often found unconscious and not breathing Hypoxemia and metabolic acidosis are inevitable features Early manifestations: Dehydration Hypotension Hemoptysis Arrhythmias Late manifestations: Secondary drowning or near drowning Infections


MANAGEMENT FIRST AID Standard CPR : Clear airway Mouth to mouth breathing Cardiac massage if heart sounds absent All cases must be hospitalized to prevent death from secondary drowning. Observe atleast for 24 hours

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IN HOSPITAL Maintain adequate oxygenation Control ventilation with oxygen PEEP if the former fails Correct electrolyte imbalance IV sodium bicarbonate for metabolic acidosis Prevent secondary effects CXR in all cases Bronchoscopic aspiration for atelectasis IV / IM dexamethasone for severe pulmonary oedema Hyperventilation or IV Mannitol for raised ICT Prophylactic antibiotic if drowning in contaminated water


MECHANISM OF DEATH Hydrocution or Immersion Syndrome Sudden exposure to cold water leads to vagal inhibition Incapacitation Eg:- Muscle stiffness due to cold and inability to protect airway Hypothermia LOC and aspiration Immersion victims are dehydrated and hypotensive. Remove them from water in a horizontal position




AETIOLOGY Accidents due to faulty domestic appliances – most common High tension lines or other installations

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TYPE AND SEVERITY Depends on: Strength of current Type of current Path taken by the current Duration of exposure Individual susceptibility Extent of grounding Characteristics of exposed part Conductivity of tissues

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INJURY Can be due to – Direct electric shock Burns High strength – Local damage more common Low strength – Systemic damage more

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HEART Myocardium – Hyperexcitable Persistent Tachycardia Shock Arrhythmias Cardiac Failure CNS Highly sensitive Spinal cord – Paraplegia, Urinary retention Brain – Convulsions, Cerebral oedema & thrombosis

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LUNGS Pneumonia Pleural effusion Ventilation disorders Hypoxia GIT Bleeding from blood vessels Damage to visceral organs KIDNEYS ARF is common EYES Cataract at a later stage

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SKIN Entry or Joule Burns Flash or Spark Burns Exit Burns Secondary infection of burns MUSCULOSKELETAL Rhabdomyolysis Compartment Syndrome Fractures


MANAGEMENT Immediate disconnection and CPR Shock – IV NS or RL Cerebral Oedema – IV Dexamethasone or Mannitol Pulmonary Oedema – IV Frusemide (Also prevents ARF) Serial arterial pH, PCV, U/O CT head and spine, Serum CPK levels, MRI Surgical management if visceral damage


PREVENTION Proper insulation Keep sockets out of reach of children Adequate insulation for the rescuer himself



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IONISING AND NON IONISING RADIATION - All humans are exposed Important man made sources X- Ray equipment Nuclear weapons Radio active medications

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EFFECTS – 2 TYPES Deterministic: Severity of injury proportional to dose of radiation. Eg:- Skin Burns, Intestinal injury Stochastic : Probability of occurrence increases with dose. But severity is independent of dose. Eg:- Carcinogenesis


SYSTEMIC EFFECTS Gonads and BM – most radio sensitive Bone – most radio resistant Heart, Skeletal muscle, Nerves – less radio sensitive BM, Intestinal mucosa, Vascular endothelium – more sensitive Head and neck Thyroid Failure Cataract and retinal damage Salivary gland failure – dental caries

Systemic Effects contd….:

Systemic Effects contd…. Mediastinum 3 times increased risk for fatal MI Chronic constrictive Pericarditis Lung fibrosis Stricture Oesophagus Spinal cord lesions In general, fatigue, anorexia, nausea, vomiting and diarrhoea occurs


ACUTE RADIATION SYNDROME Whole body exposure > 300 rads – fatal Acute exposure – mucositis, skin errhythema, BM toxicity, Radiation Enteritis CNS – Disorientation, Convulsions, Shock


4 PHASES Phase I: Within minutes – Nausea, Vomiting, Diarrhoea Phase II: Latent phase – 1 week Phase III: Critical phase (BM Failure) Neutropenia – Infection Thrombocytopenia – Hemorrhage Fever, Vomiting, Diarrhoea, Oropharyngeal Ulcers, Purpura Phase IV: Recovery phase – Temporary sterility - Malignancy may occur in later life

TREATMENT - Supportive:

TREATMENT - Supportive Correct fluid and electrolyte imbalance Treat toxemia and infection Treat hemorrhage, anemia and neutropenia Treat in aseptic condition Blood transfusion if necessary BMT may be useful


EFFECT OF RADIATION IN PREGNANCY Implantation stage - Embryonal death Stage of organogenesis – Fetal malformations, abortion More than 3 months – Stunted growth, Reduced life span, Sterility, Tendency for Leukemias and cancers

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